The 2015 PCORI Annual Meeting:
Progress in Building a Patient-Centered Comparative Clinical Effectiveness Research Community
The Transformative Effects of
Technology in Healthcare Settings:
Examples from the Field
Cathy Gurgol, MS
Program Officer, Addressing Disparities
Beth Kosiak, PhD
Senior Program Officer, Improving Healthcare Systems
Penny Mohr, MA
Senior Program Officer, Improving Healthcare Systems
October 7, 2015
Overview of PCORI’s Telehealth Portfolio
2
Presenters
• Discussant: Wendy Nilsen, PhD, Program Director, National Science Foundation
• Panelists:
– Tumaini Coker, MD and Pamela Guadarrama
– Sheridan Miyamoto, PhD; Madan Dhamar, PhD; Mike Lawson
– Renee Pekmezaris, PhD, Lawrence Murray
– Richard Katz, MD; Anita Brown; Tim Mavritte
3
Overview
4
Telehealth(or telemedicine)
Projects Across PCORI Science
5
N=20
0 1 2 3 4 5 6 7 8 9
CDR
IHS
APDTO
AD
Science Program Funded Projects
Number of Projects
Pro
gram A
rea
Condition Categories
6
Population Focuses
7*Not mutually exclusive
Portfolio Summary
8
10 studies use mobile phones as the mode of care delivery. o 2 studies do so through phone calls o 6 studies use mobile smartphone appso 2 studies use a text messaging platform
5 studies use virtual video conferencing/counseling.
13 studies use web-based portals accessible by a multitude of devices (computers, smartphones, and tablets.)
3 studies develop and implement connected data network portals.
3 studies implement an EMR provider alert algorithm tool.
Across PCORI, 20 studies incorporate technology into their interventions:
Mode of Telehealth Delivery
9
*Not mutually exclusive
10
5
13
3 3
0
2
4
6
8
10
12
14
Mobile phones Video intervention Web-basedintervention
Connected datanetwork portal
EMR alert tool
Care Delivery
10
9
5 5
17
0
2
4
6
8
10
12
14
16
18
Clinical support
Health worker support
Remote data collection
Monitoring (self- or clinician-
monitoring of health)
Bashshur B, Shannon G, Krupinski E, Grigsby J. The taxonomy of telemedicine. Telemed E Health. 2011; 17(6):484-94.
Thank you
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The 2015 PCORI Annual Meeting:
Progress in Building a Patient-Centered Comparative Clinical Effectiveness Research Community
A Patient-Centered
Tele-Behavioral Health Intervention
for Medicaid-Insured Children
Tumaini R. Coker, MD, MBAAssistant Professor of Pediatrics, Mattel Children’s Hospital UCLAAssociate Director, Health Services Research, UCLA Children’s Discovery & Innovation Institute
Pamela Guadarrama, BSTelehealth Care Coordinator, Northeast Valley Health Corporation
October 6-8, 2015
Study Overview
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Purpose of Study
Study Design
Community Partner Engagement
Study Progress
Study Purpose
• To improve access to behavioral, developmental and mental health services for children in low-income communities
Study Design
• Year 1– Intervention development
– Project Working Group process
• Years 2-3– Cluster RCT
– 6 clinical sites of an FQHC and 2 partnered mental health clinics
– Medicaid-insured children
– Primary outcome: Access
Components of Telehealth Intervention
Real-Time Videoconference
Patient Visit
Clinical Educational
Sessions with Clinicians
Clinician Communication
and Patient Coordination
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
Unfamiliarity with MHCPoor understanding of services
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
2
Phone number instabilityCold calls from MHCTiming of call from MHC
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
2
3
PCP comfortPCP-Specialty CommunicationBack-up support for PCP
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
2
3
Video Orientation
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
2
3
Telehealth Eligibility Screening
Intake and Therapy
PCP Referral
Parent connects to MHC
Psychiatry Management
Psychiatry Evaluation
MHC Eligibility Screening Process
Transfer back to
PCP
1
2
3
Telehealth Collaboration:
Educational Webinars
Case-based Transfer Sessions
Weekly Mini-rounds
Impact of Community Engagement
• Initial access for patients
• Primary care support (the carve out)
• Transfer cases/mini-rounds
• Family advocate/Telehealth care coordinator role
• Evaluation design
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Study Progress
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Year 1
• Development
Year 2• Implementation
Year 3• Evaluation
Development
Community Partner Participation
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Partner Contribution
Overall Experience
Telehealth Care Coordinator
• Telehealth care coordinator role
– Referral process
– Family advocacy
• Parent experiences
– Telehealth screening visits
– Response to technology
– Telehealth developmental/behavioral specialty visits
27
The 2015 PCORI Annual Meeting:
Progress in Building a Patient-Centered Comparative Clinical Effectiveness Research Community
Thank You!Tumaini R. Coker, MD, MBAAssistant Professor of Pediatrics, Mattel Children’s Hospital UCLAAssociate Director of Health Services Research, UCLA Children’s Discovery & Innovation Institute
Pamela Guadarrama, BSTelehealth Care Coordinator, Northeast Valley Health Corporation
The 2015 PCORI Annual Meeting:
Progress in Building a Patient-Centered Comparative Clinical Effectiveness Research Community
Patient and Provider Engagement and
Empowerment Through Technology (P2E2T2)
Program to Improve DiabetesCo-Investigators Patient Advisory Board MemberSheridan Miyamoto Mike Lawson Madan Dharmar
Principal Investigator: Heather Young
October 7, 2015
Patient Engagement: Changing the Conversation
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Project Goal and Specific Aims
Goal: Develop and evaluate an innovative program that uses nurse
health coaching with motivational interviewing techniques paired with
wireless sensor and mobile health (mHealth) technology.
Aim 1: Refine and finalize the intervention elements (nurse coaching,
wireless sensor technology and mHealth framework, relevant
outcomes) with stakeholders
Aim 2: Integrate patient-generated goals and sensor data into a
mHealth dashboard linked back into the clinical record
Aim 3: Evaluate the effectiveness of the P2E2T2 Program
on diabetes self-management
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Are we on the right track?
“I feel like if someone took the time then [say] ‘Oh, this is what you’re doing during the day. Here’s where you need to improve.’ That would be wonderful.”
“Well, I think it would be a great idea for my doctor and anybody tied to my care to be able to have that information just for the simple fact of okay, this is what you’re doing, you know, maybe we need to adjust your medications.”
“If I could see a pattern, maybe it’s not exercising or maybe it is stress or maybe I was, you know, on medication, that would -- the logical side of me would respond to that. Those are facts.”
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DATA MEANING
STEP
S
You have trouble meeting your activity goals on Mondays and Tuesdays. What happens on those days? What changes might you make?
Activity levels seem to be linked to your sleep quality at night.
Certain night time meals and alcohol intake appear to impact sleep quality and mood
Your blood pressure has improved due to changes you have made to your diet and activity in the past 3 months!
Patient Partner Participation
• The role patient advisors have played
– Language, Non-clinical perspectives, Influence the provider's perspectives
• Dissemination of program findings
• Volunteering Beyond Board Role
– Subject recruiting
– Newsletter for program
– Device testing
Study Design
Site: UC Davis Primary Care Clinics
Comparing P2E2T2 Program to Chronic Disease Management
Sample: 150 per study arm (300 total)
Primary Outcome: Self-efficacy, HgbA1C
Secondary Outcome: Readiness to Change, Quality of Life
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Patient Generated Data Integration to EHR
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UCDHS
Portal
UCDHS
Patient
Epic Chronicles
Epic ClarityEpic
Hyperspace
MyChart
3rd party
Managed
authentication
Patient Generated
Health Data
Visualization – Dashboard
PCP/Nurse Coach/Care
Team
Raw responses
stored for analysis Enables
research and
other
analytical
capabilities
UCDHS
Provider
“Actionable” summary
information within Epic
Visualization – Dashboard
Patient
Patient Generated Data Integration to EHR
How will we know if this is successful?
“Just your A1C improving. You know, really when it's all said and done,
that's your report card.”
“Betterment of your health”
“Seeing improvement in your results”
“Knowing I’m doing something right in the process of getting to better
health”
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Potential for Broader Impact
+ +
Advisory Board:• Patients• Providers• Technology Thought-
Leaders• Implementers
2 PCCs UC Davis
17 PCCs UC Davis
Investigators:
Heather Young (Principal Investigator)
Jay Han (Co-Principal Investigator)
Yajarayma Tang-Feldman
Thomas Balsbaugh
Bridget Levich
Sarina Fazio (Project Manager)
Patient Advisory Board:
Margaret Hitchcock
Mike Lawson
Diane Goodman
Maria Ibarra
Tarunesh Singh
Eric Bowser
Joe McCarthy
Acknowledgement
Provider Advisory Board:
Tom Balsbaugh, MD
Patrick Romano, MD, MPH
Richard Kravitz, MD, MPH
Victor Baquero, MD
Deborah Greenwood, PhD, RN (Sutter Health)
Antonio (Ben) Balatbat, MD (Dignity Health)
Jonalyn Wallace, RN, MSN
Prasanth Suramprudi, MD
Bridget Levich, RN, MSN
Barbara Pelletreau, RN, MPH (Dignity Health)
Kameka Brown, MD (Veterans Affairs)
Collaborators:
UC Davis Clinical and Translational Science Center
UC Davis Primary Care Clinics
Initiative for Wireless Health and Wellness Program
Center for Information Technology Research in the Interest
of Society
Technology Advisory Board:
Mike Minear (CIO)
Kent Anderson, MS
Nick Anderson, PhD
Suresh Ram, MS
Scott MacDonald, MD
Amit Pande, PhD
Nina Amenta, PhD
Thomas Nesbitt, MD, MPH
Mike Hogarth, MD
Steven Chan, MD, MBA
Dan Weberg, PhD, MHI, RN
Jana Katz-Bell, MPH
Tod Stoltz, MBA
Kwan-Liu Ma, PhD
Matthew Lange, PhD
David Lindeman, PhD
The 2015 PCORI Annual Meeting:
Progress in Building a Patient-Centered Comparative Clinical Effectiveness Research Community
Thank You!Sheridan Miyamoto, Madan Dharmar,
Mike Lawson
Patient and Provider Engagement and Empowerment Through Technology (P2E2T2) to Improve Health in Diabetes
Telehealth Self-Management in Older
Adults Living with Heart Failure in
Health Disparity Communities
42
Renée Pekmezaris, PhDPrincipal Investigator
Vice President, Community Health & Health Services ResearchAssociate Professor
Departments of Medicine & Population HealthHofstra North Shore-LIJ School of Medicine
Lawrence F. Murray, LMSWChairman, Community Advisory Board
Investigators
CollaboratorsChristian Nouryan, MAMartin L. Lesser , PhD Deborah Ahern, NP*
Kathleen Pecinka, RN, MSNAmgad Makaryus, MD*
Stacy Castillo, RN*Lorinda Bauer, MBA*
Tito Orona*Site: Nassau University Medical Center
Renée Pekmezaris, PhD
Paola DiMarzio, PhD, MPH
Rebecca Schwartz, PhD
Study Purpose & Methods
To employ a mixed methods approach to:
• Assess patient acceptance and usability of Telehealth Self-Monitoring (TM) program in African American and Latino health disparity patients with CHF (NYHA class 1-3) (Aim 1).
• Directly compare TM to standard of care in our target population (Aim 2).
44
45
Aim 1: Acceptability & Usability
Adaption Process
Original Evidence-Based TM Intervention
Components
- Daily Vital
signs upload
by patient for
clinician
review
- Weekly virtual
clinician visits
Community Advisory Board Adaptions
- CAB Focus Group 1
- CAB Theater Testing
- CAB Focus Group 2
Pilot Study Patient Adaptions
Final
Adapted TM
Intervention
Reassure
undocumented
patients, font
size,
translation
Identification of
“On the
Ground” Issues
- Focus Group: direct user feedback
46
Aim 2: Directly compare TM to SOC in our target
population
RCTComparators
TM: 1) Daily Vital Signs
2) Weekly video visit with HF nurse
SOC:
HF clinic visits for uninsured &/or care as
reimbursed by Medicare
Sample Size
104
Outcomes
1) Hospital utilization (primary)
2) ER utilization,
3) Quality of Life (Minnesota LWHF
Questionnaire)
Technology
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Pulse Oximeter Stethoscope w/ Head Phones Digital Scale
Patient Engagement Plan:
CHF Community Advisory Board
• Patients and Caregivers– Four Patients– Two Caregivers
• Patient Advocates– Health Access Specialist– Retired Deputy Commissioner of
Health and Patient Advocate– Telehealth Installation and
Patient Orientation Specialist– Hispanic Community Leader– Former Commissioner of Health
• Health Care Practitioners– Geriatric and Chronic Care
Management Expert– Heart Failure Expert– Telehealth Nurse– Pharmacist
• Health Policy and Finance– Policy Expert– Payor Expert– Health Law Expert
• Disparities Expert– Health Disparities Expert– Social Disparities Expert
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Impact
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Improved health outcomes for AA & Latino disparity patients
Potential for the study to have broad impact/uptake across the health care system
Nationwide, providers & insurers are struggling to identify ways to reduce
heart failure readmissions
Improved access, especially for older disparity patients, who are more likely to have transportation, financial & caregiver issues
Reduced hospital utilization & better quality of life, due to timely exacerbation identification & quick response
Improved self-efficacy, as weekly clinician televisits involve patients in their care management process
A Word About Comparators
& Technology
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Great variation in the telehealth literature
Two major considerations: comparators and technology
A Word About Comparators
51
The majority of telehealth studies examine outcomes (eg, hospitalizations) after discharge, when patients frequently receive home care
Most telehealth studies describe their control comparators as “usual care”, in which patients frequently receive home care
Home care is a strong transitional care intervention to prevent CHF readmissions
If we are comparing live nursing visits in home care to live nursing visits in telemonitoring , do we really expect to see a difference?
Feltner et al 2014 Systematic Review & Meta Analyses ofTransitional care interventions
FAVORABLE toward intervention AGAINST intervention
A Word About Technology
52
Great variation in telehealth interventions
Great variation in the literature re: telehealth efficacy
A Word About TechnologyKitsiou et al 2015 Technology-Specific Overview of
Home Telemonitoring Systematic Reviews
53
